Funeral_Director_Worksheet



4724400-231140DOD:_____________________________ 00DOD:_____________________________ Decedent’s Legal Name (First, Middle, Last, Suffix):___________________________________________________________________________________________________________ First Name Middle Name Last Name SuffixSex: □ Female □ Male □ UnknownSocial Security Number: __ __ __ - __ __ - __ __ __ __ □ None □ UnknownDate of Birth: __ __ / __ __ / __ __ __ __ M M D D Y Y Y YAge – Last Birthday (Years): _____________________ Under 1 Year (Months/Days): ______________ Under 1 Day (Hours/Minutes):______________Birthplace (City and State or Foreign Country): Birthplace (County):Ever in US Armed Forces? □ Yes □ No □ Unknown Residence Address (Street and Number – Include Apt. #):-2666682175259Alias: _____________________________________________________________________________00Alias: _____________________________________________________________________________Residence County: Residence State or Foreign Country:Residence Zip Code:Did Decedent live in a Township? □ Yes, decedent lived in _______________________________________________ Township □ No, decedent lived within limits of ____________________________________ (city/boro)Marital Status: □ Married □ Widowed □ Divorced □ Never Married □ UnknownSurviving Spouse’s Name (If wife, give name prior to first marriage): _____________________________________________________________________ First Name Middle Name Last NameFather’s/Parent Name (First, Middle, Last, Suffix):__________________________________________________________________________________________________________ First Name Middle Name Last Name SuffixMother’s/Parent Name Prior to First Marriage (First, Middle, Last):__________________________________________________________________________________________________________ First Name Middle Name Last Name Informant’s Name(First, Middle, Last):_____________________________________________________________________ First Name Middle Name Last NameRelationship to Decedent: Informant’s Mailing Address (Street and Number, City, State, Zip code):Decedent’s Education – Check the box that best describes the highest degree or level of school COMPLETED at the time of death. 8th grade or less No Diploma, 9th-12th gradeHigh school graduate, or GED completedSome college credit, but no degreeAssociate degree (e.g. AA, AS)Bachelor’s degree (e.g. BA, AB, BS)Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)UnknownDecedent of Hispanic Origin – Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the “No” box if decedent is not Spanish/Hispanic/Latino.No, not Spanish/Hispanic/LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latino (Specify) ________________________________UnknownDecedent’s Race – Check ONE or MORE races to indicate what the decedent considered himself or herself to be:□ White □ Korean □ Black or African American □ Vietnamese□ American Indian or Alaska Native □ Other Asian□ Asian Indian □ Native Hawaiian□ Chinese □ Guamanian or Chamorro□ Filipino □ Samoan□ Japanese □ Other Pacific Islander □ Other (Specify) ________________________________________□ Don’t Know/Not Sure □ Refused Decedent’s Single Race Self-Designation – Check ONLY ONE to indicate what the decedent considered himself or herself to be:□ White □ Korean □ Black or African American □ Vietnamese□ American Indian or Alaska Native □ Other Asian□ Asian Indian □ Native Hawaiian□ Chinese □ Guamanian or Chamorro□ Filipino □ Samoan□ Japanese □ Other Pacific Islander □ Other (Specify) _______________________________________□ Don’t Know/Not Sure □ RefusedDecedent’s Usual Occupation – Indicate type of work done during most of working life. DO NOT USE RETIRED.Kind of Business/Industry ................
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